Inspection on 12/06/08 for The Old Rectory

This inspection was carried out on 12th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Rectory 13/12/07

The Old Rectory 23/05/07

The Old Rectory 06/11/06

The Old Rectory 19/01/06

The Old Rectory 17/05/05

The Old Rectory 08/11/04

The Old Rectory 30/09/04

The Old Rectory 09/09/04

The Old Rectory 15/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Old Rectory Spring Lane Lexden Colchester Essex CO3 4AN Lead Inspector Sara Naylor-Wild Unannounced Inspection 12th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address Spring Lane Lexden Colchester Essex CO3 4AN 01206 572871 01206 573198 theoldrectory@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manager post vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (60) of places The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 60 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 21 persons) The total number of service users accommodated in the home must not exceed 60 persons 13th December 2007 Date of last inspection Brief Description of the Service: The Old Rectory is a large fully detached property that was originally built as the rectory for the local church in Lexden. The property has been considerably extended over the years to provide accommodation for up to sixty elderly people (over the age of 65) on three floors although, more recently, none of the bedrooms on the less accessible top floor have been in use and so the maximum number of residents has declined to 55. Most bedrooms are for single occupancy, although there are four double rooms. Communal space is provided with three lounges and three dining rooms situated on the ground and first floors of the home. A further small resident smoking lounge is provided on the first floor. Access between floors is provided via two passenger lifts. To the front of the home there are extensive, mature gardens. One small fully enclosed patio garden is provided to the side of the home with a second patio to the rear. Limited car parking for visitors is available inside the main entrance gate; further public car parking is available close by in Spring Lane. Bus services run along the main road at the top of Spring Lane, which provide access to/from Colchester town centre. The home provides personal care and support for residents with varying levels of dependency, including up to twenty one places for people who have dementia. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 5 The current weekly charge for a room ranges from £350.00 to £650.00. Fees do not include chiropody, hairdressing, incidental items such as newspapers and staff time to accompany people to hospital. Past inspection reports are available from the home, and from the CSCI internet website. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out over two days on the 13th and 15th May 2008. . The evidence contained in this report was gathered from discussions with people who live at the home, the managers and staff. We also undertook a tour of the premises and looked at documents relating to care, staff, and medication. The service sent us their Annual Quality Assurance Assessment (AQAA) when we asked for it. This contained information about what they felt they did well and how they were planning to improve the service in the future. We sent surveys to people living in the home and their relatives. There was a good response and the information contained in these was used to inform us on some of the outcomes for people using the service. The manager assisted the inspector at both site visits. Feedback on findings was given during the visit with the opportunity for discussion or clarification. The inspector would like to thank the manager, the staff team, and people living at the service and their relatives for their help throughout the inspection process. What the service does well: People who are considering moving into the service have their needs assessed by the service prior to them agreeing to their admission. This ensures that the service has information that will support the persons admission and that the right equipment and staff skills are in place. Everyone living at the home has a plan of care that sets out how staff should support their needs. Peoples changing health care is monitored and recorded including the outcomes of visits from health professionals. Medication is administered in a safe and accountable manner. Staff understand their responsibilities in ensuring medication is administered, recorded and stored according to the guidance of the Royal Pharmaceutical Society of Great Britain. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 7 The service aims to stimulate people who live there and offers a range of social activities. People enjoy their meals and felt the choice of food available on the menu was good. People know how to complain and have confidence in the way the service responds to their complaints. They believe the staff will listen to them and know how to protect them from incidences of abuse. The service recruits staff in a way that ensures they protect the people who live at the home. The organisation asks people for their views on how the service operates and responds to this feedback in discussions with the people who live at the service. There is a staff-training programme that provides staff with the basis of skills to meet the needs of people living at the service. The service manages people’s monies in a way that ensures they are accountable and provides clear records of any transactions. What has improved since the last inspection? What they could do better: Care planning information would benefit from greater detail in how the individual’s needs can be met. This will ensure that staff are able to offer the best level of support in a consistent way. Activities should be provided in a way that meets the individual’s abilities and interests, and this is recorded as part of their care planning. In order to demonstrate that staff have the appropriate skills to meet the needs of people living in the service, the annual staff training plan must include subjects that are raised from the peoples assessed needs. The quality assurance system operated by the service should conclude with a report detailing the services actions taken in response to the feedback they received. This will help people who participated to understand how their comments have influenced the services progress. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 8 Staff should be offered regular line management supervision that supports them in understanding how their performance is assessed, and identifies how training and development would support them in gaining the appropriate skills. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving to the home can be assured that they will be consulted about their needs and aspirations prior to there being a decision made about their moving into the home. EVIDENCE: The files relating to five people living at the home were examined to determine how their needs were assessed. The assessment document includes the social workers assessment the southern cross assessment of daily living needs and a range of risk assessment forms for pressure ulcers, dependency, moving and handling, malnutrition universal screening tool(MUST) assessment, urinary continence, bowel, falls, and additional assessments with outcomes for specific issues identified as a risk such as constipation Additionally there is an admission information page that contains details of the person and their next of kin as well as a physical and social assessment sheet The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 11 that includes the person’s own views of their needs. This gives a very individual response to the assessment and ensures that the person is consulted about their needs and the support they require. The service does not provide intermediate care. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home can be assured that the staff will understand how to support their needs, but cannot be confident that this knowledge will be documented. The people living at the home can be confident that their medication will be administered safely. EVIDENCE: The care plans of five people living at the home were read to determine how the service supports the needs identified in the person’s initial assessments. The care plans used a template common to Southern Cross services with a page for each assessed need outcome. They identify the area of need and give bullet point instructions to staff in responding to them. Care instructions are generally helpful and give some guidance to staff in meeting the person’s needs. Those related to emotional and behavioural issues due to cognitive impairments tended to state that staff should be supportive and give The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 13 encouragement rather than detailing any specific therapeutic steps they should take to reduce the person’s anxiety. The language used to describe the person’s needs varied between each plan with some being more person focused than others. In one example a person that has a cognitive impairment and wants to go home so is likely to leave the building without peoples knowledge is described as likely to ‘escape’. These terms do not indicate an awareness of the person and the reasons why they may seek to leave the home. Care plans varied in how informative the instructions to staff were and in some instances a more general instruction was given. Some plans did not contain all the information found in other documents such as the initial assessment or the daily records used by staff to record how the person’s needs are on a day-today basis. This was evidenced from discussions with staff and people living at the home on the day of the inspection. In one case the specific way in which a person with some behavioural issues should be approached was well known to staff who were able to give a detailed explanation, this information was identified in the plan of care, although the information given to staff in how to respond to this need was much less detailed. In another case a person with a medical condition that affected their diet was not known to staff serving the midday meal and was not fully documented in their plan of care. The discussions with the manager demonstrated an understanding of how the care plans should be developed to improve their support they offered to staff in meeting people’s needs. People’s health and wellbeing was monitored in a number of documents that included weight, nutrition and health professionals visit. The records support staff in understanding changes in individual’s health needs and are used to update care plans and change the action required to support them. Prior the inspection visit the Commission received information from health professionals who said they felt the service tended to not utilise local community based services fully and instead frequently called on emergency health services and the accident and emergency department of the local hospital. The service responded to these concerns directly under their complaints procedures, and the outcomes were discussed at the inspection visit. The manager stated that it is the policy of Southern Cross to refer any person who has suffered an accident to the emergency services in the first instance, and that staff were not equipped to make an assessment of the person’s health. It was recommended that the policy is reviewed to determine how this supported the quality outcomes for people living at the service and whether this was always in the best interests of their health. The deputy manager undertook the responsibility for the management of the medication system. They demonstrated an understanding of the good practice in medication administration and were working in updating the services The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 14 storage arrangements. The service had a controlled drugs cabinet with appropriate records. They were also responsible for mentoring staff that were new to the role of medication administration, and observation of this task being undertaken demonstrated a positive role model to staff. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the service can expect there to be some opportunities for activity and occupation that meets their needs and wishes. However there are not the same opportunities for all residents. EVIDENCE: There are meetings arranged for people who live at the service and their supporters. These are used as part of the services quality assurance systems and people are invited to give their views and discuss aspects of the services operation. The most recent meetings had been held only days before the inspection visit and minutes of these were not available. However minutes from previous meetings were seen. These give a commentary style record of the discussion, and it was clear that the participants brought up a number of items. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 16 It was noted that the minutes do not contain feedback of the outcomes from previous meetings, and this was discussed with the manager as a point of good practice in quality assurance. Activities are on offer in the service and include games, singing and arts and crafts. The manager reported that the planned improvements to the patio garden outside the downstairs lounge also included elements of gardening activity that people could take part in. The care planning documents do not highlight the way in which people are offered occupation and stimulation in activities, which would help staff to develop an individual approach to this area of support. People told us “the offer is always there to take part in all activities and the fact that xxx declines these is not reflection on the staff. xxx is a loner and is happy in their own world (sic)” and “They are good at providing….(Sic) day to day care and routine as much as possible they try to make it feel as much like their own home.” Visitors are welcome in the home and people felt that they could come and go at any reasonable time. . People’s bedrooms are comfortable and furnished to enable them to use them in the day, a choice that a number of people spoken with took. They told us “I do like being in my room, I have everything I need here close to hand so there is little reason for me to go out”, Another person pointed out their personal items that were adorning their room and said how much they appreciated having these things around them. The menus provided a choice and variety of meals across the week. People spoken with told us they are offered the menu choice the day before. The main meal of the day is at lunchtime and two main choices are on offer. People were generally happy with the meals on offer. However one person told us that they had chosen a meal that due to a medical condition they could not eat. The menu choice sheet showed that the right meal had been delivered, and when asked the staff serving the meal was not aware of the person’s condition. The person’s nutrition element of their care plan did indicate that the ingredient was not liked, but did not relate it to their medical condition. This was discussed with the manager as an illustration of the need for clear care planning instructions that are known to staff, so they can provide suitable information to people. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can expect to be protected by the home’s policies and procedures. They can be assured that their concerns and complaints are responded to appropriately. EVIDENCE: The service had received 7 compliments in the last 6 months from families of people who had lived at the home thanking the manager and staff for the high standard of care and support their relation received. These are shared with the staff group and stored in a compliments folder. The complaints file contains a record of all complaints received by the service and the action taken in response to the comments. In addition to these measures the manager offers a weekly managers surgery every Wednesday from 4 pm to 6 pm for people to drop in and discuss anything with them. The complaints procedure contains guidance on how to make a complaint and who to complain to with the timescales that the service will respond to issues raised with them. The management is supported by guidance in the ‘management of complaints’ policy and procedure. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 18 People spoken with during the inspection and in the surveys sent out by the Commission said that they were confident in the homes complaints procedures and knew who to speak to if they were unhappy. Prior to the inspection visit the Commission received a concern from local healthcare professionals in respect of how the service accessed the community and acute health care services on behalf of people living there. The Commission asked the service to respond to these concerns under their complaints policy. At the inspection visit the record demonstrated that the complaint had been received, the issues investigated and a meeting arranged to discuss the outcomes with the person who raised the concerns. The service has the organisations policy and procedure for responding to safeguarding issues and whistle blowing. These were updated in 2007 and reflect the current guidance and legislation relating to the protection of people form abuse. The staff undertakes training in safeguarding adults and sessions are included in the annual training plan. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the service can expect the premises to meet their needs and provide a comfortable place in which to live. However the cleanliness of some areas could be improved upon. EVIDENCE: The building of the Old Rectory is a mixture of the original rectory building dating back to the early 19th century and a more modern addition. During a tour of the premises the manager pointed out the areas where the décor had been updated as noted at the previous inspection and those where she was aiming to renew the fabric in the coming year. This was mainly in the older portion of the building that in places did look dated and worn. The manager was in the process of contracting a decorator for this work, and was in discussions with the organisation for the a reorganisation and The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 20 refurbishment of areas of the home such as the senior care station, the medication cupboards and the patio gardens outside the downstairs lounge. There was not a maintenance and refurbishment plan for the building available, and this should be addressed within the service’s quality assurance systems. Whilst some of these issues are not directly linked to the day-to-day life of people living at the home they do contribute to the dignity and confidentiality of their support. These plans were well known in the home and were confirmed by other staff spoken to during the inspection. Other areas of the home were bright, clean and tidy in appearance. People’s bedrooms were pleasantly decorated and personalised with their pictures and ornaments. People spoken with liked their rooms and the ability to make it their own. One person said “I like it here so much I don’t often like coming out”. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the service can expect to be supported by staff in suitable numbers to meet their needs. They can also be confident that that staffs have been subject to satisfactory recruitment practices. Although they cannot be assured that the staff hold all the knowledge and skills required to meet their assessed needs. EVIDENCE: The service had 47 people in residence at the time of the inspection and the staffing levels as demonstrated by the rotas were 8 or 9 care staff on duty in the waking day, with two senior care staff responsible for tasks such as dispensing medication, assisting residents during health professionals visit. There are also staff working in housekeeping and catering roles. In addition the manager and deputy manager cover managerial roles and development. The night shift is made up of four waking staff made up of one senior care staff and three care staff. From observation and discussions with people who live at the service this number gave suitable support to meet their needs. The files of five staff were looked at during the inspection visit, and these contained their application forms with full employment details of individual, an The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 22 interview checklist, reference requests and responses, and copies of Criminal Records Bureau (CRB) checks and the Department of Health’s Protection of Vulnerable Adults (POVA) list checks. The files also contained evidence of the induction process that people undertook during their initial employment at the service. This included the Skills for Care induction standards workbook and the Southern Cross induction checklist. These documents are signed off by the staff member and their mentor as and when they have demonstrated a competence in each area of knowledge. Completion of the induction should equip staff with an understanding of the service, their role and the needs of people who live there. Staff files contained a contract of employment and their signed acknowledgement for the receipt of policy documents relating to their employment such as Safeguarding and whistle blowing. Ongoing staff training was detailed in the services training matrix and annual programme planner. The training programme for June to November 2008 includes food hygiene, fire safety, manual handling, dementia awareness, abuse awareness, health and safety, first aid and NVQ 2 and 3. The training matrix updated monthly with details of who is due for training and when they have participated. For many of the subjects there was a competency check completed as part of the programme that demonstrated that staff had understood the information they had been given in the session. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at the service can be confident that they will be consulted about the way the service operates but not about how their views will influence the development of the service. EVIDENCE: At the time of the inspection the registered manager had left the service and although a manager had been appointed an application had not yet been made to register with the Commission. The post holder has many years practice in the care sector including previous management experience. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 24 From discussions with staff the new manager had already made contributions to the services development and staff were eager to move forward and work together in improving the outcomes for people living there. The services quality assurance system was looked at during the inspection. The file contained copies of surveys sent out to people living at the home and their relatives over December and January 2007/08. The returned surveys were audited and the outcomes recorded. These are then used to discuss further with people living at the home and minutes of meetings referred to these discussions. The completion of a quality system should include the publication of the survey outcomes and the services response in an action plan that will allow people to understand how their comments have influenced the homes development. The surveys give the option of identifying who the person completing them is, and in some cases this option had been chosen and issues they refer to dealt with. The service should consider the differences between an anonymous quality assurance system and their complaints system and refer people to the appropriate route. The organisation has a computer based central cash pooling system for the management of people’s monies. This provides an audit trail of all monies transactions for each individual. The systems records were considered at this visit and the management discussed with the person responsible. They provided a robust and accountable system that can be inspected at any time. The staff supervision was under review at the time of the inspection and the manager was able to outline the planned reorganisation of supervision grouping around the key worker system with approximately four staff allocated to each senior care staff member who in turn were to be supervised by the manager and the deputy manager. The current staff supervision records held on the files sampled indicated a more sporadic approach to the timing and discussions of these sessions. The majority of these were not consistent and did not always refer to one to one time with their line management, but rather a reflection of the team meeting minutes. There were some more recent records that gave a good indication of the discussion and feedback given about an individual’s development in their role. This included recommendations for future training needs. Three staff from the sample seen at the visit had completed annual appraisals in the last month with details of their performance and development needs noted for action. This process was being undertaken across the whole staff group. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 25 The service held certificates in relation to the safe operation and maintenance of equipment according their legislative responsibilities. The certificates that demonstrated this were considered at this inspection and included Electrical installation, gas safety soundness test, Lift maintenance, moving and handling hoists, water regulations, portable appliance testing, fire extinguishers and emergency lights and fire alarms. The service carries out monthly visual check of the fire safety systems and there was a fire risk assessment in place. The records included the monitoring of staff attendance at fire drills. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 3 The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement People living at the service must be supported by care plans that provide staff with information about how to best meet their needs. People living at the service must be supported by staff that have sufficient skills to meet their assessed needs. People who live at the home and other stakeholders should be provided with the outcomes of quality assurance surveys and the services action plan to this feedback. Staff must receive line management supervision that supports them in understanding their performance in their role and identifies training needs. Timescale for action 30/09/08 2. OP30 18(c)(i) 30/09/08 3. OP33 24 31/03/09 4. OP36 18(2) 31/08/08 The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP33 OP12 OP8 Good Practice Recommendations The quality assurance system should support people giving their views anonymously. Individual’s choices and preferences in how they engage in activities should be recorded as part of their care plan and this information used to offer suitable activities. Consideration should be given to the way in which people living at the home are supported following an accident, and if the services policy ensures they receive the most appropriate healthcare support. The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Rectory DS0000017974.V366897.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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